Lefebvre, Albert NEW YORK STATE DEPARTMENT OF HEALTH Gc✓"
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Gr. This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilrage, or City) in which the death occurred afterthe FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURAB E BLACK INK. Town, Vill e l /3
tered o. ..
Dist. No. (c/ o my qi.. or City..... ..... '
7).
, (If city, give street ad e
Name of deceased ...... .. .. Y�J'1 Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex )c -. ' or divorced (write the word) Date of Death l l0 19�6"
Age 7 Ye n s :..' ' Days Birthplace
Cause of Death .... ...
Certificate was signed by ... �. i.. .. �!/ M.D.
Address . ... .. .
Place of Buri (or Re oval =/ .U�
(If body is to tempo ly d fill in space la r) f
Cemetery .. Date of Burial /—/3 1. '-
(If body is to e tem orari y eld, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
same Appearing to be COMPLETE, CORRECT AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, ve recorded it in my al Record w h the above stated Register Number, and o e basis thereof I HEREBY GRANT A
PER I
to ' l
ame) / (Add'ress��r7
the to hold temporarily and ..., �'f,�� � the body
(Un erta e r person having charge of c4rp e) (In a the%�/cG!"'�PR of (state how))
Dated l.3 19 ..A6 (Signed)
Local Registrar
This Per ' is sufficient for the Removal (and Interment or Cremation)of a body to any part of the State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit(VS No. 62) is required.
POltM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of r '/VU -i rnY.-iv( was 19 76
(Interment or Cremat' n)
6.0/'7L�( fu�
(Name of Ce etery, Crematorium, etc.)
Section ,P Lot No. 3 3 Grave No. "Z
/ 7
(Signed) CC'% _�c�2��•
(P rson in Charge)
Address :�5 i l't`tt``i 7 / ,1-1n : ��( r
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date. If no
person is in charge, the FUNERAL DIRECTOR or LIWUER-
TAKER MUST SIGN ABOVE STATEMENT, write acros*,the
face of the Permit the words "No person in charge," ,and
FILE PERMIT WITHIN THREE (3) DAYS with the Registrar
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits are liable to
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.